Among the 103 women living with HIV and their children included in the study, only one baby had become infected with HIV, resulting in a MTCT rate of 1%. However, 41% of the babies included in the study were still breastfeeding and had not yet reached the point where there was no more risk of acquiring HIV through MTCT. A transmission rate of 1% could therefore be an underestimation but indicates that the rate is low. The transmission rate was lower than national numbers, 2.9% in 2015, (11) and can be compared to high-income countries, such as Sweden, where the transmission rate was lower than 0.5% in 2017 (17).
Regarding compliance to WHO guidelines, 80% of the babies had received recommended infant prophylaxis. Seven babies had not been given infant prophylaxis, only CTX-
prophylaxis. In HIV-positive infants and children who have been treated with CTX against opportunistic infections, greater survival has been shown (41). Due to the risk of acquiring HIV and not receiving immediate ART, the potential positive outcomes are considered to outweigh the risks with the treatment.
Some of the mothers stated that the reason for not receiving NVP was because it was out of stock at KHC. Lack of resources in the health care is a problem in Uganda, where only 1.4% of GDP is spent on health care by the government (14). If health care would have been more prioritized, there is a possibility that all babies could have been offered infant prophylaxis. In this study, economic issues with seeking health care were not studied. However, mothers complained about expensive transportation costs when they needed to travel to KHC more often because ART was out of stock. AAAQ (availability, accessibility, acceptability, quality) is used as a frame for the right to health with the goal that all people should receive essential
health care. Accessibility implies access to a health facility that one can afford to visit (42). Further research needs to be done to investigate if accessibility to health care is limited at KHC.
Early infant diagnosis, testing the baby before two months of age, is crucial to identify HIV- infected infants and quickly enroll them in care to minimize the very high mortality among untreated infants. The compliance to guidelines regarding testing was high at six weeks of age. Due to the risk of acquiring the infection during breastfeeding, it is of utmost importance to test the babies again when there is no more risk of acquiring HIV. Testing of babies after cessation of breastfeeding and at 18 months of age was insufficient at KHC and should be improved, so that infected babies can be identified. A final status serological test is important to rule out HIV. At KHC, rapid diagnostic tests that detect antibodies are used. An
improvement could be made by changing to combination tests that detect both antigen and antibodies, to earlier detect HIV both in pregnant women and their babies.
Breastfeeding increases the risk of MTCT by 14%. However, as the situation is today, the benefits of breastfeeding outweigh the risk of acquiring HIV in Uganda. In low-resource settings, breastfeeding has been shown to decrease mortality in pneumonia, diarrhea, and undernutrition, which are all major causes of death in children under five (36). At KHC, mothers were recommended exclusive breastfeeding for six months with introduction of complementary foods thereafter. Nearly all mothers had been breastfeeding exclusively for six months or were still exclusively breastfeeding. The health staff followed the previous WHO recommendations from 2010, to advise mothers to stop breastfeeding at twelve months of age. However, WHO stated in 2016 that breastfeeding should continue for 12-24 months or longer, until a safe diet containing all necessary nutrients can be given (36), which is not yet
part of Ugandan Guidelines and has not been implemented at KHC. As time goes by, Uganda together with other low-income countries will hopefully get closer to the situation where high-income countries are, with low rates of child mortality. There is a possibility that in the future, breastfeeding will not be needed to protect the infants and children from severe infectious diseases, with decreased MTCT-rates as a result.
A study on PMTCT in Uganda showed that 96% of the babies had been given NVP
prophylaxis, which is a higher coverage than at KHC. Regarding testing, 76% had been tested for HIV, nearly all of them during the first two months of life. The testing rates were lower than at KHC regarding early infant diagnosis. All of the mothers breastfed their babies, compared to all but one in this study. No baby was reported as HIV-positive, but not all had been tested and 24% of the mothers did not return for their children’s results. A transmission rate of 0% could therefore be misleading. However, the results indicate that compliance to guidelines is correlated with a low risk of transmission (43). The design of this study differed from ours, in that they investigated if mothers were retaining in their PMTCT programmes by following women living with HIV over time. In our study, observations were done at a
specific time point and mothers who did not seek health care at that time were therefore missed, which was a limitation of the study. Their study setting was in urban areas in the two largest cities in Uganda in medical facilities by The AIDS Support Organization, where better results could be expected than at KHC. Their conclusion was that the mothers retained in their PMTCT programmes to a high extent, whereas in this study, conclusions can be drawn only about the quality of the services given to people who are enrolled in care.